Registered Nurse Case Manager (RN)

Conifer Health Solutions•Turlock, CA

1d•Onsite

About The Position

Performs technical and administrative work required to evaluate the necessity, appropriateness and efficiency of the use of medical services procedures within our acute care facility. Responsible for clinical review of all acute and outpatient services for appropriateness based on Interqual. This individual is responsible for the management of hospital resources necessary and appropriate for achievement of desired acute and observation outcomes for his/her assigned caseload, and the coordination of appropriate LOS along with assigned hospitalists.

Requirements

Current California RN license.
2 years current acute care experience.
CM/UR experience 1-3 years.
InterQual experience.

Nice To Haves

BSN preferred.
Previous experience with Interqual criteria preferred.
Previous case management experience in an acute care setting preferred.
Certification in Case Management preferred.

Responsibilities

Assesses appropriateness of inpatient admissions and stay utilizing Interqual, and through collaborative communications with secondary reviewers and hospitalists.
Responsible for management of patient care across the acute and outpatient health care continuum.
Performs admit screen for level of appropriateness.
Reviews discharge plans prepared by MSW/Discharge Planner.
Facilitates appropriate level of care through out the hospital stay through chart review and daily rounds on unit.
Identifies variations and outcomes deviations from plan of care, communicates impact on DC Plan to hospitalist and MSW/DC Planner.
Provides clinical case management for medically complex cases.
Assures accurate patient admission order throughout hospital stay.
Provides Interqual discharge screen results when appropriate, communicates/collaborates with MSW/DC Planner to assure safe discharge.
Actively participates in interdisciplinary team meetings, keeping team members informed of changes in patient condition, admission status, level of care, coverage issues and need for discharge.
Provides interdisciplinary team members with needed insurance information.
Identifies delays in services and facilitates appropriate resolution.
Utilizes Continued Stay or Episodic Review in Interqual to track acuity of each patient in caseload; works closely with hospitalists to reduce avoidable days.
Provides concise documentation in the medical record to facilitate communication between caregivers.
Responsible for clinical aspects of discharge planning for cases on assigned unit that require clinical knowledge/expertise beyond the scope of knowledge of the MSW.
Identifies clinically high-risk patients and collaborates with MSW/DC Planner in development of discharge plan.
Refers psychosocially high-risk and new discharge planning cases to social worker.
Develops and implements discharge plans to meet patient and family needs on assigned discharge cases.
Supports MSW in facilitation of patient and family education regarding plan of care, alternatives, expected LOS and discharge plan.
Coordinates clinical documentation and reporting with social services to transfer to another facility or level of care.
Make appropriate arrangements and referrals for discharge on clinically complex cases
Responsible for utilization management.
Performs Interqual review of acute and outpatient admissions within 24 hours of admission to hospital.
Predicts and plans for patients needs from admission in collaboration with the hospitalist and/or specialists.
Utilizes Interqual criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning.
Acts in conjunction with the appropriate MSW/DC Planner on a daily basis to access the inpatient census on assigned unit for appropriate discharge service needs.
Communicates with PCP/hospitalists for resolution when patient does not meet criteria for ordered admission, continued stay or discharge. (Collaborates with EHR when contact made by their physician reviewer.)
Makes referral to Medical Director of hospitalists if proper actions not taken by attending MD.
Reports cases to Director of Case Management for final resolution with UR Medical Director per EMC Utilization Management Plan. (If no resolution to non acute admission/stay.)
Completes data collection and clinical reviews on time.
Manages overall LOS for caseload by focusing on individual patient LOS, tracks causes for delayed discharge during stay.
Identifies avoidable days, tracks daily, weekly and monthly for reporting to Director.
Works collaboratively with MSWs and hospitalists to reduce avoidable days, achieve and maintain targeted LOS for unit.
Provides information, interacts and acts as a resource for all departments to ensure appropriate use of acute care services, appropriate level of care, and appropriate unit assignment.
Educates medical staff/other health care professionals to UM strategies and principles.
Makes recommendations and provides financial resource and utilization management information to other members of the care team for work prioritization.
Works closely with hospitalists and MSW’s to move patients through the continuum appropriately.